In this article the concept of loneliness is reviewed, along with research that relates it to illness and hospitalization, two conditions that we almost all undergo at some point in our lives. These conditions are replete with loneliness, a sense of isolation, and a deep yearning, not only for health and life, but for a meaningful connection with loved ones and those who care.

When facing illness or hospitalization, we usually do not first think of loneliness, but about health, illness, survival, and possibly death. However, research indicates that the process of one’s health being evaluated, of being hospitalized and treated is replete with isolation, loneliness, anxiety, and fear – all variables that can significantly affect a person’s dealing with illness and his or her survival. The present article, thus, addresses that specific issue and examines how loneliness is actually an integral part of the health care system, hospitalization, and illness.

Illness

Illness is part of life. Some get it more often and in a more severe manner than others, but when it happens, it needs to be addressed, at times with hospitalization. Leventhal and his colleagues [1] suggested that there are several components to how people conceptualize illness: Assigning the disease a ‘title’ is very important for the patient’s behavior, since the symptoms themselves are not sufficient to initiate help-seeking behaviour, but labeling could make the difference. It is obvious that an individual will experience less emotional arousal when the label of their illness indicates a minor physical problem than if it is a more serious illness. The label carries with it information about the problem, a projection as to the length of sickness, and the possible treatment course.

Determining the cause of the illness is quite important. After a diagnosis, knowing the cause of the problem will determine the treatment to be utilized, and affect how we comply with instructions of health care professionals.

The ability of the patient and his health care professionals to control the disease and its trajectory, has to do with how people view the suggested treatment of the disease. If they, for instance, view the situation as beyond hope, they may not seek treatment, while those who believe that medical science can help them will take much more interest in their course of treatment.

Kiecolt-Glaser et al. [2] pointed out that more and more research now indicates that psychological factors are clinically significant and are correlated with immune-related health outcomes, including infectious diseases, cancer, autoimmune diseases, and HIV. Psychological variables, including loneliness, have been associated with changes in immune functioning and may weaken the body’s capacity to fight disease [3].

HospitalizationThe hospital is where we end up when we are sick, in pain, in a medical emergency, or in need of immediate and extensive medical attention. It is commonly accepted that the modern hospital environment is supposed to provide a safe and healing environment for people inflicted with a variety of illnesses, be it for short-term visits and minor health problems or more serious conditions requiring long-term treatment and care. However, a closer look may reveal that we fall somewhat short of that ideal.

Upon entering the health care system, patients in the Western hemisphere receive the most contemporary care available, benefiting from modern technology and the expertise of professional staff who are armed with the most current information about the human body and the variety of treatments that are available [4]. And despite all that, hospitalization can be one of the most distressing events people experience in their lifetime [5]. Brannon and Feist [6] observed that entering the hospital as a patient, he or she become part of a complex institution and assumes a role within that institution. Without possibly the medical personnel’s intent, the patient’s role includes, argue Brannon and Feist [6], being treated as a ‘nonperson,’ tolerating lack of information, and basically losing control of daily activities, something that most of us have. It is not uncommon for patients to be identified by their illness, as in when a physician may ask the nurse “attend to the multiple fractures in room so and so.” Patients’ identities, emotional needs and even queries about their condition are often ignored by the hospital staff [7]. In order to clarify what a patient undergoes once hospitalized, let’s look at the case of a woman when she is admitted to the hospital. First, hospitalization means the disruption in her daily routines, a change in her living environment, and having to adjust to the hospital environment. She must resign herself to the care of doctors and nurses and get used to unfamiliar surroundings and, often, unpleasant experiences associated with the course of treatment. She will most probably live now in a state of constant worry, and she must have complete faith in the medical professionals [8]. The reality of this situation is that an individual and her family are not only subject to the debilitating aspects of the physical illness but also to the added stressors inherent in the experience of being hospitalized [9,10].

Illness, with its various symptoms creates a major stressor on one’s life [11]. Pain, fatigue, and, in more severe cases, immobility and even loss of bodily functions and control put the body into a state of continuous stress [12]. Hospitalized patients experience a wide range of consequences and effects [13,14]. In general, the stress that the patient experiences is not only the physical suffering and distress but there are also negative psychological effects as well [15]. These include the uncontrollable and unpredictable nature of one’s condition, the state of apprehension and hopelessness, and even perceived threat to one’s life, which can have a considerable effect on the patient’s thoughts, emotions, and behaviours [16,17,18].

In extreme circumstances of life-threatening illnesses, when intensive, isolated care and nursing are required, the combination of these factors is enhanced and might even alter patients’ sense of identity and shake their confidence in who they truly are. They, consequently, might might feel disorganized and disengaged [19]. Indeed, the long-term psychological effects such as anxiety, depression, and post-traumatic stress disorder commonly occur in response to critical illnesses and may linger for a long while [20,21]. In addition, it was observed that simple features inherent in the design of hospital environments may negatively influence the process of patients’ recovery [4]. In general, adapting to a hospital environment and routine is often stressful. That includes having to eat hospital food which is notoriously untasty, or having to sleep on different beds. Consequently, the patient may experience emotional discomfort, as patients have minimal personal control over their choices [10,22]. The continuous noise and activity in most hospitals can lead to increased sensitivity to pain and increased need for painkillers in patients, as well as disruptions in the quality of sleep [23]. Consequently the patients’ well-being, healing, and recovery, may be aversively affected. Inadequate lighting or the absence of well-designed windows to allow exposure to adequate natural sunlight is yet another factor that has been shown to get in the way of patients’ recovery by increasing the occurrence of depression, agitation, and sleep disruptions [24].

In intensive care units, patients receive around-the-clock care due to their immobilization, being confined to bed, and often connected to multiple intravenous devices [25]. Many other factors, such as double occupancy rooms that impede patients’ privacy and quality of rest and lack of fresh air and poor ventilation systems can increase patients’ physical and emotional discomfort [4,22].

The attitudes and behaviors of the medical staff toward the patients are key factors in perceived quality of care and whether the patients can successfully cope with the stress of hospitalization [26,27]. This is essentially due to the fact that, with the exception of the (limited) visiting time of their family and friends, hospitalized patients’ social contact is limited to interaction with the medical staff. These interactions are imbalanced as well. The patient is powerless, passive, weak, and dependent, while the doctors, nurses, and supporting staff, are in complete charge of almost every aspect of the patients care, with all the knowledge, authority, and power [5].

As a consequence of this enormous gap in power and control with the medical staff, patients may be feeling emotionally distressed [26]. In such situations, many patients may experience heightened levels of anxiety because they feel deprived of control over and knowledge about their health and recovery [17,10]. It is not uncommon for patients to feel “dehumanized,” since it is not uncommon for health professionals to treat their bodies while ignoring their human spirit and the wholeness of their existence [5]. Such perception can result in considerable distress, helplessness and loneliness in patients [28]. Emotional distance and depersonalization of the patients might be their natural [29].

LonelinessLoneliness, which can involve both excruciating physical and mental suffering, is an ancient nemesis. Loneliness is implicated in numerous somatic, psychosomatic, and psychiatric diseases [30]. It is a “mundane yet arcane human affliction that is often hazardous to health and hostile to happiness” [31]. Mijuskovic [32] maintained that no one is completely self-sufficient, and the individual could not exist without the whole, the society in which one lives, and that his happiness is closely related to the community to which he belongs. Loneliness is a universal experience shared by all humans. Being a uniquely subjective experience, it is caused by the individual’s personality, environmental and social changes, and one’s history [33]. That history includes, of course, the illnesses and the cultural context of those illnesses that one may have been afflicted with.

Through the examination of philosophical and psychological attempts to understand it, and based on my 30 years of research, the following characteristics of the experience of loneliness are delineated:

1. Loneliness is an experience of separation, one that all individuals have undergone at one or more stages in their lives.2. It may arise at birth or in childhood and remain throughout one’s life, closely related to the individual infancy attachment style, but also to various trials and tribulations that they have experienced.

3. It is difficult to tolerate. Loneliness, in contrast to solitude, is painful, unwanted, and causes suffering.

4. It motivates humans to seek meaning and connection. Loneliness is instilled in everyone in order to encourage connectedness, be part of the human group, and to survive and find a role and meaning within that group.

5. It may have an evolutionary basis. Loneliness appears to have an evolutionary basis. It can be seen in nature, or alternatively on National Geographic. The animal that lags behind the herd is the one that gets to be the lion’s dinner.

Loneliness Associated with Medical Diagnosis and illness

Examining first the effects of loneliness on the body and the immune system, Cohen [34] observed that life events, including separation, loss, and feelings of hopelessness, that are associated with the experience of loneliness affect the endocrine system through abnormal secretion levels from the pituitary and adrenal glands. That may adversely affect the immune system and therefore decrease the body’s ability to fight illness and/or result in an increased risk of cancer [35]. Such a deterioration in health is most probable in persons with already compromised immune functioning, especially persons with serious and life threatening illnesses, such as Acquired Immune Deficiency Syndrome (AIDS), cancer, ALS, or Ebola [2]. Research has found that high loneliness scores are also correlated with significantly lower levels of natural killer cell activity, which are the lymphoid immune cells that play a role in cancer protection and appear to have antitumor and antiviral capabilities [3].Examining the trajectory of illnesses, studies have concluded that people without social contact—the lonely ones—are at the greatest risk of illness [36]. Thus, feeling neglected or even abandoned may not only result in a deep feeling of loneliness, but our body may malfunction as well as it struggles to carry on without the fundamental necessity of human connection, closeness, and acceptance. Mate observed that those who do not get to be close to others, or who deny their need for others end up feeling bitter and angry. Research has repeatedly demonstrated that those with social support systems were much healthier [37], whereas those with fewer social ties had increased susceptibility to illnesses [38]. In general, when close relationships are discordant, they are often associated with immune deregulation [2]. Moreover, social isolation has been recognized as an important factor in poor health, such as are cigarette smoking, high blood pressure, obesity, and sedentary lifestyle [6]. It was also found that people with higher rates of social support have better health and lower rates of mortality and those who had the fewest social ties were two to four times more likely to die than those who were well supported [39,40].

A diagnosis of an illness arouses feelings of anxiety and loneliness following the diagnosis of a disease or illness [41]. Research has established that patients undergoing diagnostic processes are prone to feelings of uncertainty and anxiety [42]. [16] “uncertainty in illness” theory, described uncertainty as a cognitive state in which a person is unable to determine the meaning of illness-related events. Uncertainty is, then, experienced when one does not have sufficient information to categorize an event. Consequently, one’s psychological state can be affected, with experiences of anxiety and feelings of helplessness which are considered threatening [16].

From the time a breast lump is discovered women experience anxiety, and it increases right up to surgery [41]. Women who were waiting for a diagnosis after an abnormal mammogram were interviewed by Thorne et al. [43]. Many of them described the time from the mammogram until the diagnosis as being “in limbo.” They experienced serious disruptions to their daily activities, suffered from insomnia, panic attacks and inability to concentrate at work. Such disconnection from normal daily routines and from loved ones may promote feelings of isolation and loneliness. Cancer patients may experience difficulties in interpersonal relationships as a result of these constraints and restrictions. As the ability to cope with the disease decreases, the quality of cancer patients’ social interactions also decreases [44,45]. Feelings of hopelessness, helplessness, and fear of death are present in the minds of patients fearing a diagnosis of cancer, and they typically lack the social and emotional support they desperately need, which may lead to feelings of loneliness [34,46].

To summarize, Illness may be a crisis for the ill person as well as for her family. A time of fear and loneliness. Chronic illness may cause a redefinition of one’s identity, and the relationship between married partners and between parents and children can be affected [47,48]. In addition, there may be concerns about the financial demands of the treatment, of absence from work, and of the future, should the ill have a terminal condition.